In the early stages of drafting what would become the Affordable Care Act (ACA), the notion of including a federal health insurance issuer in the online marketplaces engendered an intense debate.1 Advocated with a goal of promoting choice and competition, the so-called public option was to focus on the individual and small business markets.1 But it was not to be. Opposed by the health insurance industry, characterized as a “government takeover” of health care, and weighed down by concerns about a national single-payer health insurance system, the public option proved unpassable.1 In its stead emerged the far less expansive if politically palatable Consumer Operated and Oriented Plan (CO-OP) program.2 The nongovernmental, state-delimited CO-OP program was to “foster the creation of qualified nonprofit health insurance issuers to offer qualified health plans in the individual and small group markets.”3 However, the CO-OPs (health insurance providers) should not be confused with accountable care organizations (coordinated health care providers). In this Viewpoint, we review the central tenets of the CO-OP program, assess its current state of implementation, and describe its future challenges.